Acad Psychiatry DOI 10.1007/s40596-014-0037-7
EMPIRICAL REPORT
Promoting Careers in Academic Research to Psychiatry Residents Sotirios Posporelis & Akira Sawa & Gwenn S. Smith & Maxine L. Stitzer & Constantine G. Lyketsos & Margaret S. Chisolm
Received: 10 September 2013 / Accepted: 9 January 2014 # Academic Psychiatry 2014
Abstract Objective With the shift of interest in psychiatry towards patient-oriented research with clinically relevant outcomes, there is a critical need for well-trained psychiatrist–scientists. The authors report on two developmentally tailored, longitudinal research training curricula designed to use peer mentoring to bridge the gap between physicians and scientists and to promote careers in academic research. Methods The authors instituted two independent research training curricula, one for first-year and one for second-tofourth-year psychiatry residents, spanning two campuses of one institutional residency training program. Each curriculum’s participants included psychiatry residents and peer scientific investigators, and both were attended by senior scientists and departmental leaders. The authors developed and administered an anonymous survey at the end of the first cycle of the firstyear resident curriculum to assess participant attitudes. Results The first-year and second-to-fourth-year resident curricula have been implemented for 3 and 2 years, respectively. The authors observed overall participant satisfaction with the first-year curricula, independent of trainee status. Furthermore, first-year psychiatry residents reported increased interest in academic research careers after exposure to the curricula.
S. Posporelis : A. Sawa : G. S. Smith : M. L. Stitzer : C. G. Lyketsos : M. S. Chisolm Johns Hopkins University School of Medicine, Baltimore, MD, USA S. Posporelis (*) South London and Maudsley NHS Foundation Trust, London, UK e-mail: [email protected] G. S. Smith : M. L. Stitzer : C. G. Lyketsos : M. S. Chisolm Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
Conclusions Results suggest that it is possible to encourage academic research careers using peer mentoring, an innovative approach that requires minimal funding, causes little disruption to the residents’ schedule and engages the gamut of individuals involved in psychiatry care and research: psychiatrists-intraining and young non-clinician scientists-in-training. Keywords Research training curricula . Peer mentoring . Psychiatry residents Psychiatry is one of the most vibrant and exciting specialties in medicine, offering the opportunity to be part of an evergrowing, innovative, and fast-paced field aimed at alleviating the suffering of millions of individuals and their families/ caregivers. Given the limited, mechanistic knowledge of definitive etiology and pathophysiology of almost all psychiatric disorders and limited effective treatments, psychiatry is a fertile specialty for groundbreaking research. Psychiatric investigators emerge from a diverse range of scientific fields including neuroscience, pharmacology, genetics, biology, epidemiology, sociology, psychology, clinical psychiatry, and other clinical medical specialties. With the shift of interest toward the translational aspect of research with more clinically relevant, patient-oriented outcomes, there is an increasingly high demand for well-trained physician–scientists. Concerns exist not only about the paucity of new physician– scientists in general [1, 2] but about the lack of psychiatrist– researchers in particular [3]. The National Institute of Mental Health has noted a decline in the number of psychiatrist–researchers disproportionate to other medical specialties [4, 5]. Regulatory, institutional, and personal reasons have been identified behind these falling numbers [6]. In an attempt to highlight potential discrepancies between physician investigators and their nonphysician peers, Dickler et al. [1] gathered data from NIH’s Consolidated Grant Applicant File between 1964
Acad Psychiatry
and 2004 and analyzed trends in the annual number of first-time applicants for NIH R01 grants. The number of physician investigators showed little net change during this period. Realizing the need for research-competent clinicians and research-literate psychiatry residents, many academic psychiatric departments have taken action by adjusting their curriculum and developing new strategies to implement these goals. Beth Israel Medical Center developed a residency research curriculum (PART: Psychiatrists Acquiring Research Training) that is independent of both their clinical and didactic programs, with an emphasis on core competencies of research. Research is taught as a stand-alone discipline through all 4 years of residency training and scholarly activities, and accomplishments had steadily risen since the inception of PART [7]. The Medical University of South Carolina launched a 2year NIH-funded research track in 2006 called DART (Drug Abuse Research Training) to address the barriers to research training during residency [8]. DART encompasses the final 2 years of psychiatry residency training (PGY-3 and PGY-4), and its alumni are being followed for 10 years in order to assess relevant outcomes (e.g., manuscripts, abstracts, funding proposals) [8]. Different, yet successful, approaches have followed. One, by the University of California, San Diego, coordinates three federally funded summer programs focused on geriatric psychiatry-related research [9]. Another, by the U.S. Department of Veterans Affairs South Central Mental Illness Research Education and Clinical Center, established the Training Residents in Psychiatry Scholarship Program [10]. Specific to the needs of geriatric mental health research is the Advanced Research Institute. The objective of this innovative program is to promote the transition to independence for junior faculty by providing focused mentoring [11]. In light of these optimistic findings and as a first step toward attracting more young psychiatrists to academic research careers, the authors developed and implemented two developmentally tailored, longitudinal research training curricula designed to use peer mentoring to bridge the gap between clinicians and scientists and to encourage careers in academic research. The aim of this report is to describe these research training curricula and to provide qualitative and quantitative information regarding participant attitudes.
months of the fourth year is spent pursuing elective clinical and/ or research activities. As the site of the first year of psychiatry residency training and multiple postdoctoral psychiatry research fellowships, JHBMC was deemed as the ideal place to initially develop and implement a curriculum to promote academic research careers to psychiatry residents. In 2009, a committee consisting of four of the coauthors (two physician scientists [CL, MC] and two nonphysician PhD scientists [GS, MS]) developed such a career development curriculum. In an attempt to ensure early resident exposure to their peer investigators, all postdoctoral psychiatry trainees at JHBMC were invited to participate (i.e., was open to first-year psychiatry residents, not just postdoctoral fellows as is typically done in such programs [12]). Initially named the “All-Trainee Lunch,” the curriculum was designed to use peer mentoring to bridge the gap between clinicians and scientists and to encourage psychiatry residents to pursue careers in academic research. The “All-Trainee Lunch” curriculum was piloted as a quarterly program for the 2009–2010 academic year. Based on participant feedback, the curriculum was refined to a monthly program beginning in the 2010–2011 academic year. The “All-Trainee Lunch” is designed as a 2-year curriculum specifically to balance the educational needs of the postdoctoral fellows who are at the training site for 2 years (thus, there is no redundancy of content) while still providing a rich educational experience for the PGY-1s who are exposed to the curriculum at this site for 1 year only. Spanning the whole length of the academic year, the curriculum now maintains a longitudinal and fresh exposure to research training for all participants. Length (1 h), frequency (monthly), timing (12–1 pm), and provision of free lunch during the seminars ensure higher rates of attendance and smooth integration into the first-year residents’ busy clinical schedule, without being overwhelming. Now in its third full year of implementation, the curriculum’s series of seminars cover a diverse set of topics, all of which serve as an appropriate introduction to psychiatric research with a hands-on approach. These topics’ general themes are summarized below: &
Methods Program Description & The Johns Hopkins University School of Medicine (JHUSOM) has been offering training in general psychiatry since 1913. Psychiatry residents enter the training program in the internship year at the Johns Hopkins Bayview Medical Center (JHBMC). After their first year, they move to the Johns Hopkins Hospital (JHH) for the second through fourth years of their training. Six
Introduction to Perspectives of Psychiatry approach. Participants are presented with an alternative approach to the DSM and biopsychosocial models for the understanding and treatment of patients with psychiatric conditions, which was originally articulated at the JHUSOM and forms the conceptual core of its residency training program [13]. Mentorship. The development and fostering of mentoring relationships are crucial steps forward for residents interested in a research career [14, 15]. After an introduction on the scope of the curriculum, participants are introduced to the idea of mentorship, mostly in its developmental form, as a source of general and practical information related to psychiatric research [16]. In addition to peer mentoring,
Acad Psychiatry
&
&
&
&
&
they are encouraged to identify faculty members with similar research interests and compatibility on a personal level, qualities that could maintain these relationships [17, 18]. Academic promotion within the institution. The promotion process at JHUSOM is discussed in detail, giving a clear timeline of a research career path in the actual academic environment in which the participants work. Facilitation by senior investigators and departmental leaders. Common misconceptions about a researcher’s career path and/or lifestyle, identified as deterrents in the decision to follow a physician–scientist career path, are clarified by senior researchers and/or faculty members with a rich research history [19]. Clinical case presentations. Discussion of clinical cases presented by the first-year residents provides an excellent focus of discussion among residents and their peer PhD investigators. The residents gain presentation and teaching experience as they guide their peer researchers through the case, and the postdoctoral researchers gain similar experience as they guide the residents in developing clinically relevant research questions generated by the case presentation and discussion. Junior physician faculty career path presentations. Led by psychiatrists who have recently completed the residency training and are close in age and career level to the firstyear residents, these presentations encourage the residents to consider the achievability of research career paths. Junior PhD trainee (i.e., peer) and faculty career path presentations. Led by nonphysicians, these presentations offer insights on a variety of topics, including the components of an interprofessional research team and collaborations with members outside the clinical field, such as statisticians.
A similar research curriculum was subsequently instituted at JHH, the site of the second-to-fourth years of the JHUSOM psychiatry residency training program. Recognizing the need for an increased number of psychiatrist–researchers and for effective communication between psychiatrists and nonphysician psychiatric researchers, a monthly workshop seminar series was established, under the intuitive name: “Mind the Gap: Aspiring to bring clinicians and scientists together.” The curriculum is sponsored by the Johns Hopkins Schizophrenia Center. “Mind the Gap” is open to medical students, secondto-fourth year psychiatry residents, postdoctoral physicians, PhD scientists, and physician/PhD trainees, supported by faculty investigators and department leaders. Following faceto-face interviews with more than 20 scientists and clinicians of all levels, a list of seminar topics was assembled around themes that include: &
Mental status examination, psychopathology, and scientific explanations
& & & & &
An introduction to the classification of mental health disorders Neuropsychology and treatment of schizophrenia Psychosocial implications of mental illness Transcultural psychiatry Schizophrenia symptomatology in other diseases
In addition, one of the seminars was devoted to understanding better how psychotic symptoms are experienced by a patient, as well as the impact of the illness on an individual’s life. To accomplish this, a patient diagnosed with schizophrenia was invited, and, following a structured interview by one of the psychiatry residents, seminar participants had the chance to ask the patient questions. In order to optimize seminar participation, the following methods have been used: &
&
&
&
&
Weekly e-mails to an extensive database comprised of psychiatry residents, psychiatry faculty members, postdoctoral fellows, research assistants, and lab technicians. A final e-mail is sent out on the day of the workshop. Design of a dedicated webpage, part of the Johns Hopkins Schizophrenia Center website, where a list with dates, topics, and speakers can be found. http://www. hopkinsmedicine.org/psychiatry/specialty_areas/ schizophrenia/mind_gap.html Posting of an announcement with every upcoming workshop on the Johns Hopkins Science Calendar (a webpage listing all events sponsored by Johns Hopkins Medicine and other Hopkins-affiliated institutions). Posters placed in strategic JHH locations, mainly focusing on the building in which the Psychiatry department is located, outside laboratories that conduct relevant research, and various JHU cafeterias. Provision of coffee and cookies to all participants.
Each of the curriculum’s seminars lasts approximately 1 h and is organized by one of the authors (SP) who, as a resident physician–scientist from the Maudsley Hospital, recently completed a postdoctoral research fellowship in the Johns Hopkins Schizophrenia Center. Discussion facilitators, who make short presentations to initiate the discussions, are mainly second-to-fourth year residents based at JHH. Other psychiatry residents are present as participants, in addition to medical students, postdoctoral fellows, doctoral students, and faculty from a variety of backgrounds all relevant to psychiatry (e.g., biology, biochemistry, neurobiology, immunology, genetics, epidemiology, neuropsychology, and neuroscience). In its first year of implementation, “Mind the Gap” has established itself as a common ground for psychiatry residents and nonphysician researchers to meet and exchange ideas. It is an excellent networking opportunity for residents to meet similar-age peers who are pursuing a career in research.
Acad Psychiatry
Bidirectional discussion between residents and nonphysician scientists is encouraged and helps clarify misconceptions held from both sides [20] as well as facilitates translation from bedside to bench and the reverse. Residents gain insight in the biological mechanisms underlying psychopathology, adding to their understanding of mental health disorders, making scientifically based treatment decisions, and optimizing care delivery. Nonphysician scientists are helped to ask more clinically relevant questions, enhancing the translational significance of their work. Initial observations revealed evidence of the “gap” that exists between residents and researchers, with respect to clinical practice and research (e.g., use of phrases such as “WE do this, but YOU do that”), which this curriculum is hoping to close, since academic psychiatrists and nonphysician researchers ultimately have the same goal, a better future for people suffering from a psychiatric disorder, for which they will need to work together to achieve. The authors believe that it is only through close collaboration and sharing of information between clinicians and scientists that advances in neuroscience can happen and both research-training curricula provide a platform where this is possible (Table 1).
Results To evaluate the “All-Trainee” curriculum, an anonymous survey was developed and administered at the end of the pilot phase to all participants (N=11). The survey comprised of 12 items assessing (1) overall satisfaction with the seminars from all participants, e.g., “Meetings were helpful in achieving the overall goal of exposure to psychiatric research (for interns) and clinical care (for other trainees)”; (2) academic research career attitudes of all participants; and (3) reflections on the uniqueness of the curriculum by first-year psychiatry residents. The survey had four additional items targeting this special subgroup, including one on the impact of the curriculum on their academic career interest (e.g., “I am more interested in an academic research career”). The survey also
provided a prompt for free narrative comments of all trainees, as well as an open discussion about the curriculum for which comments of all trainees were recorded by one of the course instructors (MC). Respondents were asked to evaluate the survey items on a Likert-type scale, with gradual increase in strength of agreement from 1 to 5. Overall curriculum satisfaction for all trainees ranged from 3.6 to 4.6 [mean=4.1, standard deviation (SD)=0.3]. An additional aim of the survey was to compare attitudes toward the curriculum between first-year psychiatry residents (n=5) and postdoctoral fellows (n=6). It was hypothesized that first-year psychiatry residents would be as satisfied with the curriculum as the postdoctoral fellows. Mean satisfaction for first-year residents and postdoctoral fellows was 4.2 (SD=0.3) and 4.0 (SD=0.3), respectively. Satisfaction was not dependent on trainee status: there was no significant difference between first-year psychiatry residents’ satisfaction with the form and content of the curriculum compared to postdoctoral fellows (p=0.93). The curriculum aspired to endorse increased interest in academic research careers, and this was also assessed by this survey. Report of increased interest in an academic research career after exposure to the curriculum for the first-year psychiatry residents ranged from 3.3 to 5.0 with a mean of 4.0 (SD=0.8). On the free narrative section of the survey, a postdoctoral fellow provided additional written comments: “I really appreciate the effort that is being put into this training experience. I feel very fortunate to have this opportunity.” The open group discussion generated several additional comments, including one by a resident who valued “seeing the research questions that can be generated from clinical care.” The majority of the attendees found the curriculum inspiring.
Discussion The “All-Trainee Lunch” and “Mind the Gap” curricula represent a combined effort early in training to attract more physician trainees to an academic research career path and
Table 1 Summary of “Mind the Gap” curriculum’s contributions Nonphysician scientists
Clinicians
• Promote holistic view of mental health illness • Deepen understanding of psychopathology • Introduce to the practice of psychiatry in a clinical setting • Enhance effective use of diagnostic criteria in mental health disorders • Strengthen use of rigorous study inclusion/exclusion criteria • Encourage development of clinically relevant animal models and behavioral outcome measures • Support development of translational aspects of research • Promote design of studies with focus on enhancing/transforming clinical care • Foster mindfulness of the human presence/factor in illness
• Establish a channel of communication with nonphysician scientists • Foster awareness of current departmental research projects • Encourage active participation in ongoing research projects • Support evidence-based clinical practice • Reinforce how research impacts daily clinical practice • Encourage formulation of scientifically sound research questions
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bridge the gap between psychiatrists and nonphysician researchers. Both programs were designed to function with minimal funding and with little disruption to the busy clinical schedule of psychiatry residents. The curricula are innovative in that they are: (1) Longitudinal: the combined curricula include psychiatry residents from all levels. By engaging residents in their first year, the opportunity to consider the academic path early on in their careers is given; (2) Inclusive: the combined curricula include all residents regardless of previous experience in research. This ensures exposure to recent advances in research and has the potential to spark a new interest; and (3) Engaging of similar-age peers as mentors: the combined curricula include research trainees from nonphysician backgrounds, affording peer mentoring between psychiatry residents and nonphysician–scientists, which is essential for the future of psychiatric practice and research. The lack of the hierarchical dimension in a peer-mentoring relationship might make it easier to achieve communication, mutual support, and collaboration than it would be in a faculty–trainee mentoring relationship [21]. The results from a survey conducted following the completion of the pilot of the “All-Trainee Lunch” curriculum suggest that such endeavors are appealing to all psychiatry trainees, regardless of background, career stage, degree, and/ or path. It was encouraging to see that the curriculum had a positive impact on young physicians’ interest in academic research careers. These results will assist in the refinement of both clinical curricula and in the development of further research curricula within the JHUSOM psychiatry residency training program. They may also serve as a practical guide for other departments and institutions interested in creating academic research curricula for residents and postdoctoral fellows. The project also provides a background for further investigations of effective graduate medical education interventions for increasing physician interest in academic research careers. Finally, although there are advantages of a residency training program that has no separate clinical and research tracks (e.g., no second-class citizen status, rigorous clinical training), there is a relative lack of protected time for residents to engage in purely research-related activities. There are several limitations of this current study that future evaluation of the curricula will address: (1) small sample size; (2) relative lack of data on immediate knowledge, attitudes, and practice outcomes; and (3) lack of data on longitudinal outcomes, including posttraining career choice and academic productivity. In addition, results may represent an underrepresentation of the program’s impact as satisfaction data were based on the pilot (quarterly) phase of the program. Future curricular implementation and evaluation plans include (1) expansion of the topic list with inclusion of workshops on research literacy and grant writing; (2) short presentations of the same topic by both a clinician and a scientist; (3) “The Link”: based on the principles of peer mentoring, upon
entry to JHUSOM psychiatry residency training program, each resident will be linked with a young scientist at an equivalent stage of his career with similar research interests. The scientist would most likely be a postdoctoral fellow from a relevant department (e.g., neuroscience, neurology, psychiatry). “The Link” aspires to strengthen the bonds between psychiatry residents and scientists by enhancing communication and promoting future research collaborations; (4) expanded evaluation of immediate and longitudinal outcomes from a greater number of participants; and (5) multisite (beyond JHUSOM) implementation and evaluation. As equal parts of a longitudinal research training curriculum, the “All-Trainee Lunch” and “Mind the Gap” curricula are two novel, successful attempts to introduce JHUSOM psychiatry residents of all levels to academic research and foster closer communication with scientists. Simple structure and cost effectiveness suggest that it could be easily implemented in other departments and institutions as well. Implications for Educators • Given the need for physician–scientists, psychiatric residency training programs are developing, implementing, and evaluating curricula in research • Research curricula can be developed for first-year psychiatry residents and postdoctoral fellows that engage both groups of trainees • Research curricula can be implemented with little disruption to the busy clinical schedule of psychiatry residents • Research curricula can allow residents and nonphysician scientists to serve as peer mentors for one another
Implications for Academic Leaders • Close collaboration and sharing of information between clinicians and scientists will foster clinically relevant advances in both clinical and basic science • Research curricula can be developed that engage both residents and nonphysician scientists to advance collaboration and facilitate translation from bedside to bench and the reverse • Research curricula can be implemented with minimal funding and minimal disruption of the clinical care mission • Interprofessional research curricula is an innovative approach that will place the institution at the cutting edge of translational science and practice improvement.
Disclosure On behalf of all authors, the corresponding author states that there is no conflict of interest.
References 1. Dickler HB et al. New physician-investigators receiving National Institutes of Health research project grants: a historical perspective on the “endangered species”. JAMA. 2007;297(22):2496–501.
Acad Psychiatry 2. Wyngaarden JB. The clinical investigator as an endangered species. N Engl J Med. 1979;301(23):1254–9. 3. Brown N, Vassilas CA, Oakley C. Recruiting psychiatrists—a Sisyphean task? Psychiatr Bull. 2009;33(10):390–2. 4. Fenton W, James R, Insel T. Psychiatry residency training, the physician–scientist, and the future of psychiatry. Acad Psychiatry. 2004;28(4):263–6. 5. Kupfer DJ et al. Recruiting and retaining future generations of physician scientists in mental health. Arch Gen Psychiatry. 2002;59(7):657–60. 6. Yager J et al. The Institute of Medicine’s report on research training in psychiatry residency: strategies for reform—background, results, and follow up. Acad Psychiatry. 2004;28(4):267–74. 7. Roane DM et al. Ensuring research competency in psychiatric residency training. Acad Psychiatry. 2009;33(3):215–20. 8. Back SE et al. Training physician-scientists: a model for integrating research into psychiatric residency. Acad Psychiatry. 2011;35(1):40–5. 9. Jeste DV et al. UCSD’s short-term research training programs for trainees at different levels of career development. Acad Psychiatry. 2007;31(2):160–7. 10. Kunik ME et al. Growing our own: a regional approach to encourage psychiatric residents to enter research. Acad Psychiatry. 2008;32(3): 236–40. 11. Bruce ML et al. Promoting the transition to independent scientist: a national career development program. Acad Med. 2011;86(9):1179– 84.
12. Reynolds 3rd CF et al. Postdoctoral clinical-research training in psychiatry: a model for teaching grant writing and other research survival skills and for increasing clarity of mentoring expectations. Acad Psychiatry. 1998;22(3):190–6. 13. Paul R, McHugh PRS. The perspectives of psychiatry. 2nd ed. USA: Johns Hopkins University Press; 1998. 14. Hamoda HM et al. A competency-based model for research training during psychiatry residency. Harv Rev Psychiatry. 2011;19(2):78–85. 15. Sung NS et al. Central challenges facing the national clinical research enterprise. JAMA. 2003;289(10):1278–87. 16. Worley L, B.J., Hilty DM, Being a good mentor and colleague, in Handbook of career development in academic psychiatry and behavioral sciences, D.M.H. Laura Weiss Roberts, Editor 2005, American Psychiatric Publishing. p. 293–8. 17. Ramanan RA et al. Mentoring in medicine: keys to satisfaction. Am J Med. 2002;112(4):336–41. 18. Williams LL et al. The good-enough mentoring relationship. Acad Psychiatry. 2004;28(2):111–5. 19. Gilbert AR et al. A developmental model for enhancing research training during psychiatry residency. Acad Psychiatry. 2006;30(1): 55–62. 20. Martimianakis MA, Hodges BD, Wasylenki D. Understanding the challenges of integrating scientists and clinical teachers in psychiatry education: findings from an innovative faculty development program. Acad Psychiatry. 2009;33(3):241–7. 21. Kathy E, Kram LAI. Mentoring alternatives: the role of peer relationships in career development. Acad Manag J. 1985;28(1):110–32.
EMPIRICAL REPORT
Promoting Careers in Academic Research to Psychiatry Residents Sotirios Posporelis & Akira Sawa & Gwenn S. Smith & Maxine L. Stitzer & Constantine G. Lyketsos & Margaret S. Chisolm
Received: 10 September 2013 / Accepted: 9 January 2014 # Academic Psychiatry 2014
Abstract Objective With the shift of interest in psychiatry towards patient-oriented research with clinically relevant outcomes, there is a critical need for well-trained psychiatrist–scientists. The authors report on two developmentally tailored, longitudinal research training curricula designed to use peer mentoring to bridge the gap between physicians and scientists and to promote careers in academic research. Methods The authors instituted two independent research training curricula, one for first-year and one for second-tofourth-year psychiatry residents, spanning two campuses of one institutional residency training program. Each curriculum’s participants included psychiatry residents and peer scientific investigators, and both were attended by senior scientists and departmental leaders. The authors developed and administered an anonymous survey at the end of the first cycle of the firstyear resident curriculum to assess participant attitudes. Results The first-year and second-to-fourth-year resident curricula have been implemented for 3 and 2 years, respectively. The authors observed overall participant satisfaction with the first-year curricula, independent of trainee status. Furthermore, first-year psychiatry residents reported increased interest in academic research careers after exposure to the curricula.
S. Posporelis : A. Sawa : G. S. Smith : M. L. Stitzer : C. G. Lyketsos : M. S. Chisolm Johns Hopkins University School of Medicine, Baltimore, MD, USA S. Posporelis (*) South London and Maudsley NHS Foundation Trust, London, UK e-mail: [email protected] G. S. Smith : M. L. Stitzer : C. G. Lyketsos : M. S. Chisolm Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
Conclusions Results suggest that it is possible to encourage academic research careers using peer mentoring, an innovative approach that requires minimal funding, causes little disruption to the residents’ schedule and engages the gamut of individuals involved in psychiatry care and research: psychiatrists-intraining and young non-clinician scientists-in-training. Keywords Research training curricula . Peer mentoring . Psychiatry residents Psychiatry is one of the most vibrant and exciting specialties in medicine, offering the opportunity to be part of an evergrowing, innovative, and fast-paced field aimed at alleviating the suffering of millions of individuals and their families/ caregivers. Given the limited, mechanistic knowledge of definitive etiology and pathophysiology of almost all psychiatric disorders and limited effective treatments, psychiatry is a fertile specialty for groundbreaking research. Psychiatric investigators emerge from a diverse range of scientific fields including neuroscience, pharmacology, genetics, biology, epidemiology, sociology, psychology, clinical psychiatry, and other clinical medical specialties. With the shift of interest toward the translational aspect of research with more clinically relevant, patient-oriented outcomes, there is an increasingly high demand for well-trained physician–scientists. Concerns exist not only about the paucity of new physician– scientists in general [1, 2] but about the lack of psychiatrist– researchers in particular [3]. The National Institute of Mental Health has noted a decline in the number of psychiatrist–researchers disproportionate to other medical specialties [4, 5]. Regulatory, institutional, and personal reasons have been identified behind these falling numbers [6]. In an attempt to highlight potential discrepancies between physician investigators and their nonphysician peers, Dickler et al. [1] gathered data from NIH’s Consolidated Grant Applicant File between 1964
Acad Psychiatry
and 2004 and analyzed trends in the annual number of first-time applicants for NIH R01 grants. The number of physician investigators showed little net change during this period. Realizing the need for research-competent clinicians and research-literate psychiatry residents, many academic psychiatric departments have taken action by adjusting their curriculum and developing new strategies to implement these goals. Beth Israel Medical Center developed a residency research curriculum (PART: Psychiatrists Acquiring Research Training) that is independent of both their clinical and didactic programs, with an emphasis on core competencies of research. Research is taught as a stand-alone discipline through all 4 years of residency training and scholarly activities, and accomplishments had steadily risen since the inception of PART [7]. The Medical University of South Carolina launched a 2year NIH-funded research track in 2006 called DART (Drug Abuse Research Training) to address the barriers to research training during residency [8]. DART encompasses the final 2 years of psychiatry residency training (PGY-3 and PGY-4), and its alumni are being followed for 10 years in order to assess relevant outcomes (e.g., manuscripts, abstracts, funding proposals) [8]. Different, yet successful, approaches have followed. One, by the University of California, San Diego, coordinates three federally funded summer programs focused on geriatric psychiatry-related research [9]. Another, by the U.S. Department of Veterans Affairs South Central Mental Illness Research Education and Clinical Center, established the Training Residents in Psychiatry Scholarship Program [10]. Specific to the needs of geriatric mental health research is the Advanced Research Institute. The objective of this innovative program is to promote the transition to independence for junior faculty by providing focused mentoring [11]. In light of these optimistic findings and as a first step toward attracting more young psychiatrists to academic research careers, the authors developed and implemented two developmentally tailored, longitudinal research training curricula designed to use peer mentoring to bridge the gap between clinicians and scientists and to encourage careers in academic research. The aim of this report is to describe these research training curricula and to provide qualitative and quantitative information regarding participant attitudes.
months of the fourth year is spent pursuing elective clinical and/ or research activities. As the site of the first year of psychiatry residency training and multiple postdoctoral psychiatry research fellowships, JHBMC was deemed as the ideal place to initially develop and implement a curriculum to promote academic research careers to psychiatry residents. In 2009, a committee consisting of four of the coauthors (two physician scientists [CL, MC] and two nonphysician PhD scientists [GS, MS]) developed such a career development curriculum. In an attempt to ensure early resident exposure to their peer investigators, all postdoctoral psychiatry trainees at JHBMC were invited to participate (i.e., was open to first-year psychiatry residents, not just postdoctoral fellows as is typically done in such programs [12]). Initially named the “All-Trainee Lunch,” the curriculum was designed to use peer mentoring to bridge the gap between clinicians and scientists and to encourage psychiatry residents to pursue careers in academic research. The “All-Trainee Lunch” curriculum was piloted as a quarterly program for the 2009–2010 academic year. Based on participant feedback, the curriculum was refined to a monthly program beginning in the 2010–2011 academic year. The “All-Trainee Lunch” is designed as a 2-year curriculum specifically to balance the educational needs of the postdoctoral fellows who are at the training site for 2 years (thus, there is no redundancy of content) while still providing a rich educational experience for the PGY-1s who are exposed to the curriculum at this site for 1 year only. Spanning the whole length of the academic year, the curriculum now maintains a longitudinal and fresh exposure to research training for all participants. Length (1 h), frequency (monthly), timing (12–1 pm), and provision of free lunch during the seminars ensure higher rates of attendance and smooth integration into the first-year residents’ busy clinical schedule, without being overwhelming. Now in its third full year of implementation, the curriculum’s series of seminars cover a diverse set of topics, all of which serve as an appropriate introduction to psychiatric research with a hands-on approach. These topics’ general themes are summarized below: &
Methods Program Description & The Johns Hopkins University School of Medicine (JHUSOM) has been offering training in general psychiatry since 1913. Psychiatry residents enter the training program in the internship year at the Johns Hopkins Bayview Medical Center (JHBMC). After their first year, they move to the Johns Hopkins Hospital (JHH) for the second through fourth years of their training. Six
Introduction to Perspectives of Psychiatry approach. Participants are presented with an alternative approach to the DSM and biopsychosocial models for the understanding and treatment of patients with psychiatric conditions, which was originally articulated at the JHUSOM and forms the conceptual core of its residency training program [13]. Mentorship. The development and fostering of mentoring relationships are crucial steps forward for residents interested in a research career [14, 15]. After an introduction on the scope of the curriculum, participants are introduced to the idea of mentorship, mostly in its developmental form, as a source of general and practical information related to psychiatric research [16]. In addition to peer mentoring,
Acad Psychiatry
&
&
&
&
&
they are encouraged to identify faculty members with similar research interests and compatibility on a personal level, qualities that could maintain these relationships [17, 18]. Academic promotion within the institution. The promotion process at JHUSOM is discussed in detail, giving a clear timeline of a research career path in the actual academic environment in which the participants work. Facilitation by senior investigators and departmental leaders. Common misconceptions about a researcher’s career path and/or lifestyle, identified as deterrents in the decision to follow a physician–scientist career path, are clarified by senior researchers and/or faculty members with a rich research history [19]. Clinical case presentations. Discussion of clinical cases presented by the first-year residents provides an excellent focus of discussion among residents and their peer PhD investigators. The residents gain presentation and teaching experience as they guide their peer researchers through the case, and the postdoctoral researchers gain similar experience as they guide the residents in developing clinically relevant research questions generated by the case presentation and discussion. Junior physician faculty career path presentations. Led by psychiatrists who have recently completed the residency training and are close in age and career level to the firstyear residents, these presentations encourage the residents to consider the achievability of research career paths. Junior PhD trainee (i.e., peer) and faculty career path presentations. Led by nonphysicians, these presentations offer insights on a variety of topics, including the components of an interprofessional research team and collaborations with members outside the clinical field, such as statisticians.
A similar research curriculum was subsequently instituted at JHH, the site of the second-to-fourth years of the JHUSOM psychiatry residency training program. Recognizing the need for an increased number of psychiatrist–researchers and for effective communication between psychiatrists and nonphysician psychiatric researchers, a monthly workshop seminar series was established, under the intuitive name: “Mind the Gap: Aspiring to bring clinicians and scientists together.” The curriculum is sponsored by the Johns Hopkins Schizophrenia Center. “Mind the Gap” is open to medical students, secondto-fourth year psychiatry residents, postdoctoral physicians, PhD scientists, and physician/PhD trainees, supported by faculty investigators and department leaders. Following faceto-face interviews with more than 20 scientists and clinicians of all levels, a list of seminar topics was assembled around themes that include: &
Mental status examination, psychopathology, and scientific explanations
& & & & &
An introduction to the classification of mental health disorders Neuropsychology and treatment of schizophrenia Psychosocial implications of mental illness Transcultural psychiatry Schizophrenia symptomatology in other diseases
In addition, one of the seminars was devoted to understanding better how psychotic symptoms are experienced by a patient, as well as the impact of the illness on an individual’s life. To accomplish this, a patient diagnosed with schizophrenia was invited, and, following a structured interview by one of the psychiatry residents, seminar participants had the chance to ask the patient questions. In order to optimize seminar participation, the following methods have been used: &
&
&
&
&
Weekly e-mails to an extensive database comprised of psychiatry residents, psychiatry faculty members, postdoctoral fellows, research assistants, and lab technicians. A final e-mail is sent out on the day of the workshop. Design of a dedicated webpage, part of the Johns Hopkins Schizophrenia Center website, where a list with dates, topics, and speakers can be found. http://www. hopkinsmedicine.org/psychiatry/specialty_areas/ schizophrenia/mind_gap.html Posting of an announcement with every upcoming workshop on the Johns Hopkins Science Calendar (a webpage listing all events sponsored by Johns Hopkins Medicine and other Hopkins-affiliated institutions). Posters placed in strategic JHH locations, mainly focusing on the building in which the Psychiatry department is located, outside laboratories that conduct relevant research, and various JHU cafeterias. Provision of coffee and cookies to all participants.
Each of the curriculum’s seminars lasts approximately 1 h and is organized by one of the authors (SP) who, as a resident physician–scientist from the Maudsley Hospital, recently completed a postdoctoral research fellowship in the Johns Hopkins Schizophrenia Center. Discussion facilitators, who make short presentations to initiate the discussions, are mainly second-to-fourth year residents based at JHH. Other psychiatry residents are present as participants, in addition to medical students, postdoctoral fellows, doctoral students, and faculty from a variety of backgrounds all relevant to psychiatry (e.g., biology, biochemistry, neurobiology, immunology, genetics, epidemiology, neuropsychology, and neuroscience). In its first year of implementation, “Mind the Gap” has established itself as a common ground for psychiatry residents and nonphysician researchers to meet and exchange ideas. It is an excellent networking opportunity for residents to meet similar-age peers who are pursuing a career in research.
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Bidirectional discussion between residents and nonphysician scientists is encouraged and helps clarify misconceptions held from both sides [20] as well as facilitates translation from bedside to bench and the reverse. Residents gain insight in the biological mechanisms underlying psychopathology, adding to their understanding of mental health disorders, making scientifically based treatment decisions, and optimizing care delivery. Nonphysician scientists are helped to ask more clinically relevant questions, enhancing the translational significance of their work. Initial observations revealed evidence of the “gap” that exists between residents and researchers, with respect to clinical practice and research (e.g., use of phrases such as “WE do this, but YOU do that”), which this curriculum is hoping to close, since academic psychiatrists and nonphysician researchers ultimately have the same goal, a better future for people suffering from a psychiatric disorder, for which they will need to work together to achieve. The authors believe that it is only through close collaboration and sharing of information between clinicians and scientists that advances in neuroscience can happen and both research-training curricula provide a platform where this is possible (Table 1).
Results To evaluate the “All-Trainee” curriculum, an anonymous survey was developed and administered at the end of the pilot phase to all participants (N=11). The survey comprised of 12 items assessing (1) overall satisfaction with the seminars from all participants, e.g., “Meetings were helpful in achieving the overall goal of exposure to psychiatric research (for interns) and clinical care (for other trainees)”; (2) academic research career attitudes of all participants; and (3) reflections on the uniqueness of the curriculum by first-year psychiatry residents. The survey had four additional items targeting this special subgroup, including one on the impact of the curriculum on their academic career interest (e.g., “I am more interested in an academic research career”). The survey also
provided a prompt for free narrative comments of all trainees, as well as an open discussion about the curriculum for which comments of all trainees were recorded by one of the course instructors (MC). Respondents were asked to evaluate the survey items on a Likert-type scale, with gradual increase in strength of agreement from 1 to 5. Overall curriculum satisfaction for all trainees ranged from 3.6 to 4.6 [mean=4.1, standard deviation (SD)=0.3]. An additional aim of the survey was to compare attitudes toward the curriculum between first-year psychiatry residents (n=5) and postdoctoral fellows (n=6). It was hypothesized that first-year psychiatry residents would be as satisfied with the curriculum as the postdoctoral fellows. Mean satisfaction for first-year residents and postdoctoral fellows was 4.2 (SD=0.3) and 4.0 (SD=0.3), respectively. Satisfaction was not dependent on trainee status: there was no significant difference between first-year psychiatry residents’ satisfaction with the form and content of the curriculum compared to postdoctoral fellows (p=0.93). The curriculum aspired to endorse increased interest in academic research careers, and this was also assessed by this survey. Report of increased interest in an academic research career after exposure to the curriculum for the first-year psychiatry residents ranged from 3.3 to 5.0 with a mean of 4.0 (SD=0.8). On the free narrative section of the survey, a postdoctoral fellow provided additional written comments: “I really appreciate the effort that is being put into this training experience. I feel very fortunate to have this opportunity.” The open group discussion generated several additional comments, including one by a resident who valued “seeing the research questions that can be generated from clinical care.” The majority of the attendees found the curriculum inspiring.
Discussion The “All-Trainee Lunch” and “Mind the Gap” curricula represent a combined effort early in training to attract more physician trainees to an academic research career path and
Table 1 Summary of “Mind the Gap” curriculum’s contributions Nonphysician scientists
Clinicians
• Promote holistic view of mental health illness • Deepen understanding of psychopathology • Introduce to the practice of psychiatry in a clinical setting • Enhance effective use of diagnostic criteria in mental health disorders • Strengthen use of rigorous study inclusion/exclusion criteria • Encourage development of clinically relevant animal models and behavioral outcome measures • Support development of translational aspects of research • Promote design of studies with focus on enhancing/transforming clinical care • Foster mindfulness of the human presence/factor in illness
• Establish a channel of communication with nonphysician scientists • Foster awareness of current departmental research projects • Encourage active participation in ongoing research projects • Support evidence-based clinical practice • Reinforce how research impacts daily clinical practice • Encourage formulation of scientifically sound research questions
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bridge the gap between psychiatrists and nonphysician researchers. Both programs were designed to function with minimal funding and with little disruption to the busy clinical schedule of psychiatry residents. The curricula are innovative in that they are: (1) Longitudinal: the combined curricula include psychiatry residents from all levels. By engaging residents in their first year, the opportunity to consider the academic path early on in their careers is given; (2) Inclusive: the combined curricula include all residents regardless of previous experience in research. This ensures exposure to recent advances in research and has the potential to spark a new interest; and (3) Engaging of similar-age peers as mentors: the combined curricula include research trainees from nonphysician backgrounds, affording peer mentoring between psychiatry residents and nonphysician–scientists, which is essential for the future of psychiatric practice and research. The lack of the hierarchical dimension in a peer-mentoring relationship might make it easier to achieve communication, mutual support, and collaboration than it would be in a faculty–trainee mentoring relationship [21]. The results from a survey conducted following the completion of the pilot of the “All-Trainee Lunch” curriculum suggest that such endeavors are appealing to all psychiatry trainees, regardless of background, career stage, degree, and/ or path. It was encouraging to see that the curriculum had a positive impact on young physicians’ interest in academic research careers. These results will assist in the refinement of both clinical curricula and in the development of further research curricula within the JHUSOM psychiatry residency training program. They may also serve as a practical guide for other departments and institutions interested in creating academic research curricula for residents and postdoctoral fellows. The project also provides a background for further investigations of effective graduate medical education interventions for increasing physician interest in academic research careers. Finally, although there are advantages of a residency training program that has no separate clinical and research tracks (e.g., no second-class citizen status, rigorous clinical training), there is a relative lack of protected time for residents to engage in purely research-related activities. There are several limitations of this current study that future evaluation of the curricula will address: (1) small sample size; (2) relative lack of data on immediate knowledge, attitudes, and practice outcomes; and (3) lack of data on longitudinal outcomes, including posttraining career choice and academic productivity. In addition, results may represent an underrepresentation of the program’s impact as satisfaction data were based on the pilot (quarterly) phase of the program. Future curricular implementation and evaluation plans include (1) expansion of the topic list with inclusion of workshops on research literacy and grant writing; (2) short presentations of the same topic by both a clinician and a scientist; (3) “The Link”: based on the principles of peer mentoring, upon
entry to JHUSOM psychiatry residency training program, each resident will be linked with a young scientist at an equivalent stage of his career with similar research interests. The scientist would most likely be a postdoctoral fellow from a relevant department (e.g., neuroscience, neurology, psychiatry). “The Link” aspires to strengthen the bonds between psychiatry residents and scientists by enhancing communication and promoting future research collaborations; (4) expanded evaluation of immediate and longitudinal outcomes from a greater number of participants; and (5) multisite (beyond JHUSOM) implementation and evaluation. As equal parts of a longitudinal research training curriculum, the “All-Trainee Lunch” and “Mind the Gap” curricula are two novel, successful attempts to introduce JHUSOM psychiatry residents of all levels to academic research and foster closer communication with scientists. Simple structure and cost effectiveness suggest that it could be easily implemented in other departments and institutions as well. Implications for Educators • Given the need for physician–scientists, psychiatric residency training programs are developing, implementing, and evaluating curricula in research • Research curricula can be developed for first-year psychiatry residents and postdoctoral fellows that engage both groups of trainees • Research curricula can be implemented with little disruption to the busy clinical schedule of psychiatry residents • Research curricula can allow residents and nonphysician scientists to serve as peer mentors for one another
Implications for Academic Leaders • Close collaboration and sharing of information between clinicians and scientists will foster clinically relevant advances in both clinical and basic science • Research curricula can be developed that engage both residents and nonphysician scientists to advance collaboration and facilitate translation from bedside to bench and the reverse • Research curricula can be implemented with minimal funding and minimal disruption of the clinical care mission • Interprofessional research curricula is an innovative approach that will place the institution at the cutting edge of translational science and practice improvement.
Disclosure On behalf of all authors, the corresponding author states that there is no conflict of interest.
References 1. Dickler HB et al. New physician-investigators receiving National Institutes of Health research project grants: a historical perspective on the “endangered species”. JAMA. 2007;297(22):2496–501.
Acad Psychiatry 2. Wyngaarden JB. The clinical investigator as an endangered species. N Engl J Med. 1979;301(23):1254–9. 3. Brown N, Vassilas CA, Oakley C. Recruiting psychiatrists—a Sisyphean task? Psychiatr Bull. 2009;33(10):390–2. 4. Fenton W, James R, Insel T. Psychiatry residency training, the physician–scientist, and the future of psychiatry. Acad Psychiatry. 2004;28(4):263–6. 5. Kupfer DJ et al. Recruiting and retaining future generations of physician scientists in mental health. Arch Gen Psychiatry. 2002;59(7):657–60. 6. Yager J et al. The Institute of Medicine’s report on research training in psychiatry residency: strategies for reform—background, results, and follow up. Acad Psychiatry. 2004;28(4):267–74. 7. Roane DM et al. Ensuring research competency in psychiatric residency training. Acad Psychiatry. 2009;33(3):215–20. 8. Back SE et al. Training physician-scientists: a model for integrating research into psychiatric residency. Acad Psychiatry. 2011;35(1):40–5. 9. Jeste DV et al. UCSD’s short-term research training programs for trainees at different levels of career development. Acad Psychiatry. 2007;31(2):160–7. 10. Kunik ME et al. Growing our own: a regional approach to encourage psychiatric residents to enter research. Acad Psychiatry. 2008;32(3): 236–40. 11. Bruce ML et al. Promoting the transition to independent scientist: a national career development program. Acad Med. 2011;86(9):1179– 84.
12. Reynolds 3rd CF et al. Postdoctoral clinical-research training in psychiatry: a model for teaching grant writing and other research survival skills and for increasing clarity of mentoring expectations. Acad Psychiatry. 1998;22(3):190–6. 13. Paul R, McHugh PRS. The perspectives of psychiatry. 2nd ed. USA: Johns Hopkins University Press; 1998. 14. Hamoda HM et al. A competency-based model for research training during psychiatry residency. Harv Rev Psychiatry. 2011;19(2):78–85. 15. Sung NS et al. Central challenges facing the national clinical research enterprise. JAMA. 2003;289(10):1278–87. 16. Worley L, B.J., Hilty DM, Being a good mentor and colleague, in Handbook of career development in academic psychiatry and behavioral sciences, D.M.H. Laura Weiss Roberts, Editor 2005, American Psychiatric Publishing. p. 293–8. 17. Ramanan RA et al. Mentoring in medicine: keys to satisfaction. Am J Med. 2002;112(4):336–41. 18. Williams LL et al. The good-enough mentoring relationship. Acad Psychiatry. 2004;28(2):111–5. 19. Gilbert AR et al. A developmental model for enhancing research training during psychiatry residency. Acad Psychiatry. 2006;30(1): 55–62. 20. Martimianakis MA, Hodges BD, Wasylenki D. Understanding the challenges of integrating scientists and clinical teachers in psychiatry education: findings from an innovative faculty development program. Acad Psychiatry. 2009;33(3):241–7. 21. Kathy E, Kram LAI. Mentoring alternatives: the role of peer relationships in career development. Acad Manag J. 1985;28(1):110–32.
